PATHOLOGIC  PHYSIOLOGY,  A NEGLECTED 
FIELD. 

CHAIRMAN’S  ADDRESS  BEFORE  THE  SECTION  ON  PATH- 
OLOGY AND  PHYSIOLOGY,  AT  THE  FIFTY-SIXTH  ANNUAL 
SESSION  OF  THE  AMERICAN  MEDICAL  ASSOCIATION 
PORTLAND,  ORE.,  JULY  11-14,  1905. 


WINFIELD  S.  HALL,  Ph.D.,  M.D. 

Professor  of  Physiology,  Northwestern  University  Medical  School. 
CHICAGO. 


Not  many  generations  ago  physiology  was  taught  in 
connection  with  anatomy  only,  and  was  a simple  state- 
ment of  the  functions,  as  then  understood,  of  the  vari- 
ous structures  described  by  the  anatomist.  It  was  Haller, 
who  in  his  ^^Elements  of  Physiology,^^^  outlined  the  field 
of  physiology  and  clearly  established  the  boundary  line 
between  that  subject  and  anatomy.  Since  Haller’s  time 
physiology  has  been  recognized  as  a separate  branch  of 
medicine  and  soon  after  the  publication  of  Haller’s  Ele- 
ments, provision  began  to  be  made  by  the  medical  fac- 
ulties for  the  teaching  of  this  subject  in  a separate  de- 
partment. 

Begun  as  an  appendage  of  normal  human  anatomy,  it 
continued  as  normal  human  physiology,  gradually  broad- 
ening into  animal  and  plant  physiology.  Great  as  has 
been  the  activity  in  the  field  of  morphology,  that  in  the 
field  of  physiology  has  been  scarcely  less  until  the  mass 
of  facts  and  principles  of  physiology  already  firmly  es- 
tablished is  so  great  that  tiie  two  years’  course  in  experi- 

1.  Elementa  Physlologlse,  In  six  volumes,  1757-1765. 


P 154.JO 


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mental  and  didactic  instruction  in  physiology  now  usu- 
ally given  in  medical  schools  suffices  simply  to  present 
such  fundamental  principles  and  facts  of  the  science 
as  may  be  applied  later  in  clinical  medicine.  Further- 
more, great  as  this  material  is,  it  includes  only  the  dis- 
cussion of  the  functions  of  the  normal  individual.  In 
other  words,  the  course  of  physiology  as  now  given  is 
one  in  normal  physiology  only. 

If  we  turn  now  to  the  subject  of  pathology  as  pre- 
sented to-day  in  our  medical  schools,  we  find  that 
histopathology — presented  usually  in  the  second  year — 
deals  almost  exclusively  with  modifications  of  the  struct- 
ure of  the  cells  and  tissues  of  the  body,  while  the  didac- 
tic course  accompanying  the  microscopic  work  deals 
usually  with  the  field  of  general  pathology  covering 
such  topics  as  hydremia,  anemia,  hemorrhage,  transu- 
dation, thrombosis  and  embolism;  atrophy,  degenera- 
tion, pigmentation  and  necrosis;  hypertrophy,  hyper- 
plasia, metaplasia  and  regeneration;  inflammation; 
parasites,  animal  and  plant;  the  relation  of  micro-or- 
ganisms to  disease,  infection  and  immunity;  infectious 
diseases ; tumors. 

One  searches  the  chapters  of  general  pathology  in  vain 
for  any  sections  that  deal  adequately  with  the  problem 
of  the  physiology  of  disease. 

Taking  up  the  field  of  special  pathology  as*  usually 
presented  in  the  third  and  fourth  years  of  the  medical 
course,  one  finds  that  the  postmortem  furnishes  the 
material  for  study.  The  points  of  fundamental  impor- 
tance at  the  postmortem  as  it  is  conducted  by  our  lead- 
ing pathologists  are:  (1)  To  confirm,  or  disaffirm,  the 
diagnosis  of  the  condition  as  made  by  the  attending  phy- 
sician; (2)  to  gain  information  that  will  make  the  diag- 
nosis of  similar  cases  more  secure  in  the  future;  (3) 
to  increase  our  knowledge  of  diseased  conditions  of  the 


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body.  With  these  ends  in  view  it  is  customary  to  preface 
the  postmortem  examination  by  the  reading  of  the  clin- 
ical history  of  the  case  in  hand,  followed  by,  first,  an 
examination  of  the  body  to  determine  gross  conditions, 
demonstrating  all  evident  changes  of  the  gross  conditions 
as  the  examination  proceeds ; second,  preserving  portions 
of  each  diseased  tissue  or  organ  for  later  microscopic 
examination.  Such  a postmortem  examination  requires 
from  one  to  two  hours,  not  including  the  many  hours 
that  may  be  later  devoted  to  the  study  of  microscopic 
changes. 

The  accumulated  material  from  the  numerous  post- 
mortems affords  museum  material  for  gross  study  as 
well  as  microscopic  material  for  study  in  connection  with 
various  topics  in  clinical  pathology. 

I believe  that  the  above  account,  though  brief,  gives  a 
fair  summary  of  the  work  now  being  accomplished  in  our 
pathologic  laboratories.  I think  it  is  not  unfair  to  other 
departments  of  the  medical  school  to  say  that  the  work 
of  the  pathologic  department  is  the  most  important 
work  in  any  one  department  of  the  medical  course,  and 
the  work  now  given  in  the  larger  institutions  could 
hardly  be  improved  on  in  the  time  that  is  devoted  to  it. 

' It  appears  to  me,  however,  that  a very  important  phase 
of  pathology  and  physiology  has  as  yet  received  scant 
attention  from  medical  teachers.  The  postmortem  af- 
fords a golden  opportunity  for  the  study  of  the  clinical 
history,  particularly  of  the  symptomatology,  of  the  case 
in  the  light  of  the  postmortem  findings.  The  symptoma- 
tology of  disease  represents  nothing  more  or  less  than 
modified  functions  as  observed  in  diseased  conditions. 
That  there  is  a definite  relation  between  the  symptoms 
observable  in  a disease  and  structural  changes  that  go 
on  in  the  cells,  tissues  or  organs  can  not  be  gainsaid. 
It  may  be  difficult  to  establish  this  relation,  but  the 


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pathologists  should  not  be  satisfied  with  their  work 
until  eyery  disturbance  of  function  has  been  traced  to 
some  disturbance  of  structure.  The  disturbance  of 
structure  accompanying  malnutrition  might  be  so  slight 
as  the  simple  difference  in  the  zymogen  granules  of  the 
pancreas,  or  in  some  obscure  physical  or  physico-chem- 
ical change  in  the  cells  of  the  thyroid  gland,  while  a 
derangement  of  the  mind  might  be  associated  with  a 
slight  change  in  the  Mssl  granules  in  the  cortical  cells  of 
the  brain,  or  in  a slight  modification  in  the  space  rela- 
tions (^‘^contiguity”)  of  cell-processes  in  the  brain  cen- 
ters. 

As  stated  above,  the  postmortem  affords  an  opportun- 
ity for  the  study  of  the  relation  of  disturbed  function 
(symptomatology)  to  the  diseased  structure.  Such  an 
attempt  on  the  part  of  the  pathologist  to  enter  into  the 
discussion  of  this  problem  in  connection  with  the  post- 
mortem examination  would  involve  the  expenditure  of 
at  least  twice  as  much  time  as  is  usually  now  spent  on  a 
postmortem  examination.  In  many  cases  this  would 
entail  the  necessity  of  making  fewer  postmortem  exam- 
inations than  is  desirable. 

The  question  might  be  asked,  “Why  should  not  the 
physiologist  cover  this  field  and  present  to  the  students 
normal  and  pathologic  physiology  We  will  say  in 
answer  to  that  question:  The  physiologist  presents  nor- 
mal physiology  during  the  first  two  years  of  the  medical 
course.  The  students  have  not  progressed  far  enough 
in  the  study  of  pathologic  conditions  to  enter  under- 
standingly  into  a consideration  of  the  relation  between 
symptomatology  and  pathology.  Thus  we  find  that  im- 
portant as  this  field  is,  neither  the  physiologist  nor  the 
pathologist — one  for  the  lack  of  preparation  of  his  stu- 
dents, the  other  for  the  lack  of  time — can  take  up  this 
most  important  subject.  The  student  therefore  enters 


« 


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on  the  study  of  clinical  medicine  and  surgery  with  a 
knowledge  of  normal  structure  and  function,  and  also 
a knowledge  of  diseased  structure,  but  no  knowledge  of 
diseased  function.  The  clinician,  in  his  presentation  of 
a clinical  case,  may  or  may  not  discuss  the  symptomatol- 
ogy of  a case  from  the  standpoint  of  physiology.  If  an 
attempt  is  made  at  this  at  all  it  is  more  or  less  inci- 
dental to  the  discussion  of  diagnosis,  of  differential  di- 
agnosis and  therapeutics.  The  relation  of  symptoma- 
tology to  diagnosis  on  the  one  hand  and  to  therapeutics 
on  the  other,  so  far  overshadows  in  the  mind  of  the  clin- 
ician its  relation  to  pathology  on  the  one  hand  and  nor- 
mal physiology  on  the  other,  that  very  little  attention 
is  given  to  these  last  two  phases  of  symptomatology. 

I believe  that  the  most  important  step  to  be  taken  in 
scientific  medicine  is,  first,  to  determine  and  next  to 
teach  every  student  of  medicine  the  relation  between 
symptomatology  and  pathology,  and  this  teaching  should 
be  a systematic  course  given  to  students  taking  clinical 
medicine  and  surgery,  and  should  be  divorced  from  any 
discussion  of  diagnosis  or  therapeutics,  so  that  the  un- 
divided attention  of  both  student  and  instructor  would 
be  directed  to  the  solution' of  problems  of  the  relation 
of  modified  function  (symptomatology),  to  modified 
structure  (pathology).  It  might  be  given  by  a pathol- 
ogist, a physiologist  or  a clinician.  In  either  case  the 
preparation  of  the  instructor  could  not  be  deemed  ade- 
quate unless  he  were  well  versed  not  only  in  physiology 
and  pathology,  but  also  in  clinical  medicine. 

One  naturally  asks  at  this  point  whether  there  exists 
a literature  of  this  subject.  Krehl,  professor  of  inter- 
nal medicine,  University  of  Strassburg,  Germany,  has 
prepared  a most  admirable  work  of  600  pages  entitled 
^Tathologic  Physiology;  A Treatise  for  Students  and 


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Physicians/^^  The  third  edition  of  this  work  was  pub- 
dished'  in  Leipsic  in  1904,  The  first  edition  appeared 

about  a decade  ago.  Earlier  editions  were  not  trans- 
lated into  English,  and  it  has  had  a very  limited  use  in 
Germany  and  among  advanced  men  in  other  lands.  An 
English  translation  of  this  admirable  work  is  just  now 
completed  by  Dr.  Hewlett  of  J ohns  Hopkins  University. 
Professor  Krehl  treats  this  subject  from  the  standpoint 
of  the  clinician  following  the  classification  of  the  path- 
ologist, and  harmonizing  his  treatment  at  every  point 
with  the  latest  findings  in  physiology. 

The  question  of  the  classification  of  the  subject-mat- 
ter is  one  of  no  small  importance,  and  is  a question  to 
which  I have  given  considerable  thought.  Eor  the  pur- 
poses of  the  physiologist  and  the  pathologist,  Krehhs 
method  is  advantageous.  It  is,  however,  questionable 
if  such  a classification  would  make  the  work  as  conven- 
ient as  a manual  for  the  student  and  practitioner  as 
would  a classification  on  the  basis  of  diseases,  following 
that  of  works  on  internal  medicine. 

A preliminary  chapter  or  ^^part^^  of  such  a treatise 
should  deal  with  general  pathologic  physiology,  setting 
forth  ’the  relation  between  the  various  disturbances  of 
function  and  various  lesions  of  disease.  Eor  example  : 
Variations  of  pulse,  with  causes  of  same;  variations  of 
peripheral  circulation,  with  causes  for  same;  variations 
if  distribution  of  blood,  with  causes  of  same;  variations 
of  rate  or  character  of  respiration,  with  causes;  varia- 
tions of  digestive  processes,  with  causes  of  same;  and 
so  on  briefly  throughout  the  list  of  body  functions. 

Following  this  should  be  the  main  body  of  the  treat- 
ise in  which  diseases  of  the  circulatory  system  might  oc- 
cupy the  opening  chapter.  Taking  up  any  particular 

2.  Pathologische  Physiologie,  3rd  Edition,  by  Dr.  Ludolph  Krehl. 
Published  by  Vogel,  Leipzig,  1904. 


disease  there  should  be  a brief  description  of  a typical 
case  as  to  etiology,  pathology  and  symptomatology.  Un- 
der the  head  of  pathologic  physiology,  each  S3rmptom 
should  be  discussed  as  to  its  causes  and  its  relation  to 
the  pathologic  findings.  Diagnosis  and  treatment  need 
not  be  mentioned.  The  discussion  of  typical  cases  of 
each  disease  would  suffice. 

I present  a plea  for  the  preparation  of  such  a manual 
as  above  outlined  and  for  such  a course  as  above  sug- 
gested, because  I believe  these  are  the  most  urgent  needs 
of  medical  pedagogy. 


